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ADJUSTMENTS OF THE INFANT TO EXTRAUTERINE LIFE1

CONTENT
ANATOMY OF FETAL CIRCULATION BREATHING o ONSET o CAUSES o EXPANSION OF THE LUNGS PRESSURES EXPANSION o SURFACTANT DEFINITION FUNCTION SECRETION o THE PRESSURE-VOLUME/COMPLIANCE CURVE CIRCULATION o OVERVIEW OF THE CHANGES o PRIMARY CHANGES IN PULMONARY & SYSTEMIC VASCULAR RESISTANCES o CLOSURE OF THE FORAMEN OVALE CLOSURE FATE OF THE VALVE o CLOSURE OF THE DUCTUS ARTERIOSUS o CLOSURE OF THE DUCTUS VENOSUS DEFINITION DUCTUS VENOSUS CLOSURE o SUMMARY

Guyton A.C. & Hall J.E. (2006). Textbook of Medical Physiology. 11th edition. Philadelphia, Elsevier Saunders. Pp. 1044 1047: UNIT XIV Endocrinology and Reproduction > 83 Fetal and Neonatal Physiology > Adjustments of the Infant to Extrauterine Life

ANATOMY OF FETAL CIRCULATION2

Relative oxygenated blood reaches via the umbilical vein and the ductus venosus the inferior vena cava In the inferior vena cava it is mixed with deoxygenated blood out of the body: portal vein etc. via the inferior vena cava the mixed blood arrives at the right atrium o from the RA the relative oxygenated blood streams via the foramen ovale into the left atrium o the relatively deoxygenated blood out of the venae cavae streams via the right ventricle into the pulmonary artery. Because of the high vessel resistance in the longs the blood streams via the ductus arteriosus into the aorta Here it mixes with the relative oxygenated blood out of the left ventricle Umblical arteries bring part of the blood back to the placenta

http://www.curoservice.com/parents_visitors/lungs_circulation/pop_foetal_1.htm

BREATHING
ONSET within seconds after loss of the placental connection with the mother. The child has a normal respiratory rhythm within less than 1 minute after birth 1. slightly asphyxiated state incident to the birth process (stimulus to the respiratory center) 2. sensory impulses that originate in the suddenly cooled skin See FLOWCHART: Causes of Breathing 1. surface tension of the viscid (viscidus [L, -da, -dum] = kleverig) fluid that fills the alveoli 2. negative inspiratory pressure caused by breathing of the normal neonate PROCESS Initially the alveoli are collapsed

CAUSES

EXPANSION OF THE LUNGS

PRESSURES

EXPANSION

Exceeding of the drempelwaarde of 25 mm Hg of negative inspiratory pressure Opening of the alveoli further respiration can be effected with relatively weak respiratory movements FIRST INSPIRATIONS (of the normal neonate) extremely powerful, usually capable of creating as much as 60 mm Hg negative pressure in the intrapleural space a substance normally secreted into the alveoli that decreases the surface tension of the alveolar fluid To allow the alveoli to open easily during inspiration By: surfactant-secreting cells = type II alveolar epithelial cells Onset: last 1 - 3 months of gestation (development) See FIGURE: Pressure-volume Curves of the Lungs of a Neonate immediately after Birth Observe, first, the lower part of the curve beginning at the zero pressure point and moving to the right: Inflation of the lungs The curve shows that the volume of air in the lungs remains almost exactly zero until the negative pressure has reached -40 centimeters water (-30 mm Hg Then, as the negative pressure increases to -60 centimeters of water, about 40 milliliters of air enters the lungs Deflation of the lungs considerable positive pressure, about +40 centimeters of water, is required because of viscous resistance offered by the fluid in the bronchioles Effect van pulmonale surfactans Pulmonale surfactans zorgt voor een linksverschuiving van de druk/volume curve van de long: a lesser negative inspiratory pressure in the lungs is needed for inflation, conversely a higher positive inspiratory pressure is needed for deflation

SURFAC- DEFINITANT TION FUNCTION SECRETION

THE PRESSUREVOLUME/ COMPLIANCE CURVE

CIRCULATION
OVERVIEW OF THE CHANGES 1. Primary Changes in Pulmonary and Systemic Vascular Resistances at Birth 2. Closure of the Foramen Ovale 3. Closure of the Ductus Arteriosus 4. Closure of the Ductus Venosus 1. loss of the tremendous blood flow through the placenta doubles the systemic vascular resistance aortic pressure + pressures in the left ventricle and atrium 2. expansion of the lungs Great decrease of pulmonary vascular resistance reduction of: the pulmonary arterial pressure, right ventricular pressure, and right atrial pressure expansion of the lungs and how it reduces the resistance to blood flow through the lungs: no longer compression of the blood vessels as was in the unexpanded fetal lungs dilation of the lung blood vessels that were constricted in fetal life due to hypoxia changes in pulmonary and systemic resistances low right atrial pressure and high left atrial pressure blood attempts to flow backward through the foramen ovale; that is, from the left atrium into the right atrium, rather than in the other direction, as occurred during fetal life closure of the small valve that lies over the foramen ovale on the left side of the atrial septum prevention of flow through the foramen ovale 2/3 of people: permanent closure valve becomes adherent over the foramen ovale within a few months to a few years and forms a permanent closure 1/3 of people: no permanent closure permanent closure does not occur, the left atrial pressure throughout life normally remains 2 to 4 mm Hg greater than the right atrial pressure, and the backpressure keeps the valve closed
The ductus arteriosus also closes, but for different reasons

PRIMARY CHANGES IN PULMONARY & SYSTEMIC VASCULAR RESISTANCES

CLOSURE OF THE FORAMEN OVALE

CLOSURE

FATE OF THE VALVE

CLOSURE OF THE DUCTUS ARTERIOSUS/BOTALLI

1. increased systemic resistance elevates the aortic pressure while the decreased pulmonary resistance reduces the pulmonary arterial pressure 2. backflow of blood from the aorta into the pulmonary artery through the ductus arteriosus, rather than in the other direction as in fetal life 3. increased oxygenation of the blood flowing through the

CLOSURE OF THE DUCTUS VENOSUS

DEFINITION DUCTUS VENOSUS

CLOSURE

SUMMARY

ductus decreased prostaglandin E1 production 4. functional closure of the ductus arteriosus: marked constriction of the muscle wall of the ductus arteriosus after only a few hours: within 1 - 8 days, the constriction is usually sufficient to stop all blood flow de bij het embryo bestaande verbindingsweg tussen de vena umbilicalis sinistra en de vena cava inferior; oblitereert later tot ligamentum venosum. In fetal life, the portal blood from the fetus's abdomen joins the blood from the umbilical vein, and these together pass by way of the ductus venosus directly into the vena cava immediately below the heart but above the liver, thus bypassing the liver Although the ductus venosus rarely fails to close, we know almost nothing about what causes the closure. 1. Stop of blood flow through the umbilical vein immediately after birth: continuation of blood fow through the ductus venosus 2. Strong contraction and closure of the muscle wall of the ductus venosus within 1 to 3 hours 3. Rise of portal venous pressure portal venous blood flows through the liver sinuses See FIGURE: Veranderingen id circulatie direct na de geboorte & See: How the Body Works: Circulatory Changes at Birth http://www.youtube.com/watch?v=NIbL5eMwG04

FLOWCHART: Causes of Breathing


initiation: 1. slightly asphyxiated state incident to the birth process 2. sensory impulses that originate in the suddenly cooled skin infant who does not breathe immediately progressively more hypoxic and hypercapnic respiratory center child ordinarily begins to breathe (within seconds)

breathing

surfactant, that lowers alveolar surface tension. The surfactant layer consists of an aqueous, proteinaceous hypophase covered with a monomolecular phospholipid film that is primarily composed of dipalmitoyl

phosphatidylcholine and phosphatidylglycerol. Surfactant also contains several types of proteins. Pulmonary surfactant serves several major functions in the economy of the lung, but it primarily aids in reducing the surface tension of the alveolar cells. The reduction of surface tension means that less inspiratory force is needed to inflate the alveoli, and thus the work of breathing is reduced. In addition, without surfactant, alveoli would tend to collapse during expiration. In fetal development, surfactant appears in the last weeks of gestation and coincides with the appearance of lamellar bodies in the type II cells.

FIGURE: Pressure-volume Curves of the Lungs of a Neonate immediately after Birth

FIGURE: Organization of the fetal circulation

Ductus venosus

(Modified from Arey LB: Developmental Anatomy: A Textbook and Laboratory Manual of Embryology. 7th ed. Philadelphia: WB Saunders Co, 1974.)

DIAGRAM: the fetal circulatory system


showing relative distribution of blood flow to the different vascular areas. The numerals represent the percentage of the total output from both sides of the heart flowing through each particular area.

FIGURE: The Foramen Ovale & Ductus Arteriosus

FIGURE: Veranderingen id circulatie direct na de geboorte


Foetale circulatie neonatale circulatie B A

A+ B: PRIMARY CHANGES IN PULMONARY & SYSTEMIC VASCULAR RESISTANCES